A tumor was then felt at the base of the left posterior lobe. The tumor was about the size of a small hen's egg, felt nodular and considerably harder than the surrounding brain substance. On removing the brain, the tumor was almost completely torn away, because as now appeared the tumor was attached to the brain by an exceedingly slender pedicle. Examination showed that the tumor sprang from about the middle of the inferior surface of the posterior lobe; in other words, from the floor of the left lateral ventricle. The brain pedicle presented some vessels which were still connected with the vessels of the choroid plexus of the left lateral ventricle. The tumor is irregularly round, nodular and considerably harder to the touch than the brain tissue. It is darker in color than the latter, covered with pia arachnoid, and some vessels of moderate size can be seen on the surface. The greatest diameter runs from before backward, and is 134 to 2 inches. The sagittal diameter from above downward is about 1/4 inches, while the width of the tumor from side to side is 14 inches. In situ the tumor was so located that it pressed upon the inferior and left lateral surface of the middle lobe of the cerebellum and also against the left side of the pons. Upwardly the tumor had pressed upon the floor of the left lateral frontal, and the brain tissue had here been softened considerably, so that it was torn into when the brain and tumor were removed from the skull. The tumor is evidently solid throughout, and when small pieces were taken out for microscopical examination the cut surface and the whole character of the tumor gave the impression that it is a glioma. Subsequent microscopical examination confirms diagnosis of glioma. CASE 3. A man, aged 36 years, had been suffering with headaches for more than a year. These pains were not absolutely localized, but began in the frontal region and radiated towards the back of the head. One of the early symptoms was the loss of vision, in one eye, first towards the temporal side and gradually also to the nasal side, so that when I first saw him he had only light perception in one eye and the other totally blind. The next important symptom he observed was a staggering gait with a tendency to fall to the left side. There was a spontaneous nystagmus which was rhythmic and was horizontal as well as rotary. The examination of the fundus showed a double optic atrophy. The pupils were small and did react, but slightly. The ears were normal in every particular and turning, as well as hot or cold water tests of the vestibular apparatus, did not appear to change the nystagmus one particle. The remaining physical findings, including spinal fluid and blood examinations, were negative. Radiogram showed a distended sella turcica. sultation with a competent neurologist confirmed my diagnosis of a cerebellar tumor, and operation was recommended. Exposing the posterior cerebral as Con well as the cerebellar hemispheres, there was no evidence of any pathologic change. Intracranial pressure was not increased; pulsation was normal. Certainly no tumor could be palpated anywhere. Subsequent to the operation the patient developed a meningitis, and died ten days later. Post-mortem examination revealed a brain, grossly normal, but in the cerebral portion of the hypophysis there appeared an enlargement, the size of a hazelnut, which filled out a distended sella turcica. Examination of this growth proved it to be a tumor of the hypophysis (microscopical examination). The nystagmus which was present in this case, and rarely occurring with tumors of the hypophysis, was the one symptom that misled us. Had we been at this time familiar with the pointing sign of Barany, we would probably have been led to a correct diagnosis. Of 8 cases of brain tumor, there was made a correct localization diagnosis in 5. This number does not include gummata. The pathologic types were cyst, osteoma or exostosis, fibrosarcoma, glioma. The locations were two in the motor area, one occipital (supratentorially), one pontine cerebellar angle, one fronto-parietal, one at base of frontal lobe. Five were operated on with a mortality of 75 per cent. In not one instance did the radiogram reveal the tumor. Spinal punctures were made in 7 of the 8 cases, and only in one was there any increase in pressure, and in all was a negative Noguchi globulin or Nonne test present. TUMORS OF THE HYPOPHYSIS Considerable progress has been made during the past five years in the pathology, diagnosis and surgical treatment in diseases of the hypophysis, especially since Cushing, Eiselsberg and Hirsch have so thoroughly elaborated this field. Of special interest is the aid of the radiogram in the diagnosis and the treatment by the intranasal route in the treatment. In performing the following operations on cadavers, Horsley, Krause, Eiselsberg, Hochenegg, Chiari, McArthur, Frazier, (transnasalorbital and sinus route); Loews, Halstead (supralabial transnasal route), and Kanavel, West, Citelli and Hirsch (transnasal and septum route), I found that for tumors confined to the sella turcica the nasal route, preferably Hirsch's modern method, is the easiest of performance; however, if the greater portion of the tumor is diagnosed to diagnosed to be located intracerebrally, the method of Frazier is best suited. The operation by way of the palate is certainly difficult of performance in man. The cases which I have observed were several cases of acromegaly, and three other cases diagnosed only at operation or post-mortem. The previously cited case, erroneously diagnosed as cerebral tumor, as well as the two following supposed naso-pharyngeal fibro-sarcoma cases, illustrate the necessity of refining our diagnostic methods. The cases of advanced acromegaly are, of course, easily diagnosed, but unfortunately not amenable to surgical treatment. CASE 1. seventeen months had constant headaches across the frontal region, radiating backwards to the occiput. One of the first symptoms he noted was the rapid loss of vision in the left eye. During the last three months the sight of his right eye has also much diminished. The left eye had also turned outward about six months ago. About eight months ago his nasal breathing began to be impaired, and now he is compelled to breathe through his mouth. His nose was widened considerably between his eyes, and his whole face has assumed a larger size. An attempt was made to remove some tissue (middle turbinate) by a specialist, but the bleeding was so severe that he was compelled to defer the completion of the operation. The microscopic examination of the tissue then removed showed a small round-cell sarcoma. The that in the naso-pharynx. The patient regained consciousness for a few hours, and died on the third day from meningitis. Post-mortem was not permitted. The histological examination of the tissue removed revealed a small round-cell sarcoma. question in the diagnois is: Was this a tumor primarily of the hypophysis, or was this a naso-pharyngeal sarcoma with secondary involvement of the brain? I am inclined to believe it was the former, since the headaches and eye symptoms preceded the nasal obstruction symptoms. This condition may be divided into three great classes, from the diagnostic and therapeutic A man, aged 41 years, has for the past standpoints, namely: (1) Basal fracture, (2) Fractures not including the base, (3) Combined. In the basal fractures the otologist is frequently interested because of the symptoms referable to the ear. The bleeding from the external canal is considered one of the pathognomonic signs. The symptoms of irritation or loss of function. of the internal ear are considered of great value in the diagnosis of this condition. X-ray diagnosis is of very little value when the fracture is confined to the base, or through the petrous portion of the temporal bone. In fractures of the remaining portion of the skull, symptoms of hemorrhage, especially from the middle meningeal artery, are the most important. It is here that the x-ray is of inestimable value in the diagnosis. In the fractures involving both base and other parts of the skull, both mentioned symptoms will be manifest. Examination: Both nostrils were occluded posteriorly, and in the left nostril was seen a tumor, which bled very freely when touched. Post-nasal examination revealed the tumor filling out the entire naso-pharynx. Transilluminations, absolute darkness of both antra-but the frontal sinuses appeared fairly clear. The x-ray picture, antero-posterior, revealed both antra cloudy, but the left more so. The frontal and ethmoidal regions fairly clear. X-ray, lateral exposure, showed an obliteration of the sphenoid sinus and the sella turcica. My diagnosis was sarcoma of the naso-pharynx, involving the antrum and sphenoid, pressing on the optic nerves. Operation: Preliminary ligation of the left external carotid arteries. I employed the Löwe method of making an incision under the upper lip, severing the attachment of the nose from the appertura pyriforme, and the cheeks from the superior maxilla, and thus raise the face. The septum in its entirety, the middle turbinate and ethmoidal labyrinth on both sides were removed. The tumor involved the ethmoid. In order to prevent the blood from flowing into the throat the post-nasal space was tamponed as soon as the tumor was removed from the nasopharynx. When the tumor was removed from the sphenoidal region there were no evidences of the wall of this sinus, but instead there was a large cavity, in the bottom of which there were the dura and the optic chiasm. The antra on both sides were filled with a tumor mass of the same character as INTRACRANIAL HEMORRHAGE These, aside from fractures, can usually be diagnosed when the history, the focal symptoms and the aid of spinal puncture are taken advantage of. My experience in this class of cases has taught me that it is very easy to diagnose them, and that early operation gives most satisfactory results, both in fractures aside from the basal and spontaneous subcortical hemorrhage. The use of urotropin in large doses, as much as 150 grains a day, has undoubtedly aided in the treatment of basal fractures. I herewith cite an illustrative case of each variety: CASE 1. A man, aged 47 years, was overcome by heat and fell from his chair, probably striking his head on a stone pavement. He was unconscious when brought to the hospital, twelve hours after the injury. There was nobody present when he fell from his chair and, therefore, we could get no history as to how he struck his head. Examination showed a marked facial twitch of his left side. The left leg and arm were in tonic contractions. The pupils were reacting normally, and there was no spontaneous nystagmus. No fundus change with the ophthalmoscope. X-ray negative. Pulse, respiration and temperature normal. A consultation with a neurologist, who suggested a spinal puncture, resulted in the diagnosis of hemorrhage into the left lateral ventricle, since the spinal fluid was bloody. He advised conservative treatment. I could not help thinking that the bleeding was cortical or, rather, subdural, most probably from the middle meningeal, and therefore decided to operate. I found a fracture of the internal table in the temporal region; the dura at this point was tense and bluish-discolored. On opening the dura I found a clot covering the entire half of the cerebrum and after its removal found the bleeding middle meningeal artery close to the base of the skull. By elevating the dura and passing a suture about the artery, I was enabled to stop the bleeding. Drainage by rubber tissue of the previously located blood clot and closure of the wound resulted in the recovery of the patient. CASE 2. A man, aged 27 years, was brought to the County Hospital by a man who had run into him with his automobile, stating that the auto struck the man on the head, knocking him unconscious. By the time he arrived at the hospital he had regained consciousness, and only appeared a little dazed. The accident happened so suddenly that, when questioned, he stated that while he was loading some heavy barrels, one slipped and struck him in the head and caused his present trouble. He also stated that the barrel had a nail protruding on the side, and that that nail caught inside of his ear and caused it to bleed. Patient's story and that of the party who brought him in did not agree at all. Examination revealed a swelling on the left side of his head, which had a doughy feeling. There was no tenderness. There were no evidences of a fracture by palpation. The pupils .reacted normally. No evidences of any twitching or paralysis of any part of the body, and the sensation appeared normal. The reflexes, with the exception of a slight right-sided Babinski, were normal. Vision normal. Hearing in both ears apparently normal. The left ear was bleeding quite profusely, and upon washing out the blood with great care with warm distilled water, a rent in the tympanic membrane and evidence of blood behind it was seen. The warm water irrigation did not produce any nystagmus. The x-ray picture could not be taken, owing to the time of the day that the patient was brought to the hospital, and at once the operation had to be done. Under general anesthesia I made the incision over the greater prominence of the doughy tumor on the side of the head, from the frontal to the occipital bone. The swelling was an edema and not a hematoma. On exposing the bone there was a fracture extending from the frontal bone near the superior orbital border, back below the superior curved line of the occiput. The separation of the fractured bones was one-sixteenth of an inch. From the middle of this fracture line ran several fractures in various directions, to the right and left. Fresh oozing was seen to come through one of the lower posterior fracture lines, so I removed this part of the calvarium to find the source of the bleeding. As soon as that was accomplished a very free bleeding was seen to come from the great longitudinal sinus region. Exposing the exact bleeding point of the above-mentioned sinus, I placed my finger over the tear and placed a purse-string suture about the opening. There was still a great deal of bleeding lower down, close towards the torcular herophili. Exposing this second tear in the great longitudinal sinus, I was unable to apply the same management as in the first, owing to its close proximity to the torcular. I therefore placed a suture to either side of the tear, placing a gauze sponge over the bleeding point and tying the two threads over the sponge. This stopped the bleeding. The wound was closed except over the location of this sponge. Patient lived for nearly thirty-six hours and the coroner's report revealed the ante-mortem findings. The interesting point was the terrific size and extent of fractures and nevertheless the absence of any grave or marked symptoms of either irritation or paralysis. CASE 3. A woman, aged 33 years, was thrown from a cable car and was picked up unconscious. She was bleeding quite freely from both external ears and inspection revealed rents in both the membranes. For the next four days there was a discharge of clear fluid in considerable quantities from both ears. While the patient regained complete consciousness, she could not hear the loudest noise. The patient received very large doses of urotropin, but the usual test for it in the clear fluid escaping from the ears did not reveal its presence. The copper reaction was positive as in normal cerebro-spinal fluid. After ten days, and while the patient was still absolutely deaf, but complained of being dizzy, although there was no evidence of any spontaneous nystagmus, I applied the caloric reaction, and very quickly obtained a compound nystagmus, first in testing one ear and then the other. Six weeks later the patient began to hear and after two months recovered almost complete normal hearing. The consultation with an otologist in this case is worthy of mentioning since the authority made the positive statement that the patient would very likely die from meningitis and if she did live would be absolutely deaf, neither of which occurred. CASE 4. A young man, aged 27 years, was run over by an automobile, the wheels passing over his forehead. He was brought to the North Chicago Hospital in a stuporous semi-conscious condition, and it was very difficult to arouse him. Both eyes and eyelids were suffused with blood. The right eye had an external strabismus and the pupil was dilated and did not react. The fundus in both eyes was normal. Over the right eye and frontal sinus was a soft fluctuating swelling, but no crepitation or movable fragment could be made out. X-ray showed a distinct fracture in three places right over the frontal sinus. My diagnosis was a fracture of the external table of the frontal sinus. The patient received large doses of urotropin. The next morning he was brighter and answered intelligently some of the questions put to him. His vision was double. He complained of considerable frontal headache, although the pulse and temperature were normal. Spinal puncture negative; other laboratory and physical examination negative. Decided on operation. Under local anesthesia, as soon as the skin and periosteum over the right frontal sinus were incised, I encountered a soft mass, whitish in character, which by immediate examination (frozen section) proved to be cerebral structure. Removing all "that was on top of the depressed fragment and lifting the same out, I found that both anterior and posterior walls of the frontal sinus, including the floor and supraorbital margin, were driven into the frontal lobes of the brain and displaced a part of the brain tissue in front of it, just beneath the skin and periosteum. Shaving off the mangled cerebral tissue, I attempted to bring the dura together and drained. Patient made an uneventful recovery, including the disappearance of his diplopia and papillary paralysis. INTRACTABLE TIC DOULOUREAUX The radical removal of the Gasserian ganglion for the relief of the severe neuralgias, devised by Hartley Krause, has for a time been checked on account of the great mortality from this operation, but recently, since the technic in brain surgery has been simplified, this procedure has received a new impetus, especially in the cases where all other methods have failed to produce relief. A more recent advance to produce result without the radical operation is the injection of the ganglion with alcohol. With this procedure I have no personal experience. This condition has in the last four years received considerable attention because many cases were relieved of the severe pain for various periods of time by the injection of alcohol into the nerves. The reports, especially from the neurologist sources, from this method of treatment are flattering. It has been my experience with cases that I treated by this method that it was of slight benefit, at least so far as lasting effects are concerned. I cite an interesting case in which the ganglion was completely removed, but the patient did not receive the expected relief. CASE 1. A young man, aged 26 years, had for the past year suffered a great deal of severe pain, which was distributed over the entire course of the trifacial nerve on the right side. When I first saw him I noted that almost all the teeth on that side had been extracted, and he had been treated by internal medication. The almost constant pain was so severe that the attending physician was compelled to keep him under the influence of opiates. The x-ray revealed nothing diagnostic, nor did the physical or laboratory examination explain the cause of this neuralgia. I first injected peripherally the supraorbital, infraorbital and mental nerves with full strength alcohol. This gave no relief. I then made a deep injection towards the base of the skull in the region of the foramen rotundum and ovale without any result. I did observe considerable resistance to the needle when I reached the skull base. I then resected the three nerves mentioned before and pulled them out of their foramen as well as from the soft tissues of the forehead, cheek and lower lip (neuraxeresis). This brought slight relief for about a week. After about two weeks of observation and then a consultation with a neurologist, who had declared that the patient was hysterical, in the worst form, probably wanting morphin (for which he begged pitifully), I decided to perform the resection of the Gasserian ganglion. I employed the method suggested by Cushing, namely, subtemporal resection of the zygoma. No difficulty was encountered in the technic. The middle meningeal artery bleeding was very easily controlled by pressure in the region of the foramen spinosum. The greatest care was exercised in severing the ophthalmic branch and not injuring the cavernous sinus. The posterior root being severed, the ganglion was removed, not entirely intact, but sufficiently preserved to find under the microscope that it was neuroglia structure, the same as a normal ganglion has. The patient recovered from the operation without any trouble, and for about three days did not complain of pain at all. Then he gradually began to cry from pain, now especially se vere in the base of the tongue. In less than a week he would cry aloud, the same as he formerly did, and required morphin to control the pain. We now did decide that he must be a malingerer or hysterical, and he was told that he might leave the hospital. Two months later he returned, having been treated in the meantime by internal medication, with no avail. He now showed great emaciation and a tumor was seen below the right ear and under the lower jaw of the same side. This tumor was very firm to the touch and was not particularly painful. I proposed operation, but he refused, went home and by personal communication I heard that he was operated on by a general surgeon for the removal of a tumor of the base of the skull (sarcoma), and that he died within a day or two after the operation. This case teaches that a removal of the ganglion may not relieve the pain, and I have no explanation matic), with connective tissue walls, and directof it. EXTERNAL HYDROCEPHALUS L. Shortly after hearing the reports of L. McArthur on the operation for the relief of marked external hydrocephalus, a case of that nature came under my observation, and I decided to attempt the same procedure. CASE. A child, .one year and seven months old, had rickets in the severe form. It was never able to stand up and none of the special functions, such as sight and hearing, appeared to be developed. It never cried, and otherwie was very much malnourished. It could not lift its large head. It could move its legs and arms, and the reflexes were normal. Examination of the eyes, external as well as fundi and muscular movements, appeared negative, and the ears showed no deviation from the normal. When asleep the loudest noise would not awaken it, but irrigation with cold water in either ear produced a compound nystagmus. The general examination was that of rickets and the laboratory findings, including a Wassermann of the blood and cerebrospinal fluid, were negative. The spinal puncture revealed the fluid under pressure; otherwise it was normal. Operation: A temporal osteo-periosteal flap was made on the right side, the size of four centimeters, with the base upwards and exposing the dura. A skin incision was continued downwards over the zygoma, in front of the auricle, and over the masseter muscles. A dural flap was made, with the base down, and the too sudden escape of cerebro-spinal fluid was prevented by holding a sponge over this area. Making a sort of tube out of this dural flap and suturing it with fine catgut, its free end was implanted into the loose tissues, over the masseter muscles in the cheek. The osteo-periosteal flap was brought down and the entire skin incision united. Firm pressure bandage was applied for forty-eight hours, removing it at intervals of three hours, so as to allow an establishment of a flow. After the bandage was taken off there appeared a marked swelling over the entire side of the face, and on the fifth day an opening was established in the suture line, from which clear cerebrospinal fluid escaped. The discharge from this fistula continued for seven weeks, not decreasing very much. At this time the child developed a violent diarrhea and after three days died. No post-mortem was permitted. ENCEPHALOCELE The report of this most interesting case is made with the purpose of bringing out several new points in the pathology, diagnosis and treatment, with special reference to the temporal bone. This condition may be properly classed among the class of congenital brain cysts (not trau ly communicating with the ventricles. CASE 1. A baby was brought to the service of Dr. Emil G. Beck shortly after birth. He diagnosed the condition as that of congenital bilateral encephalocele (Fig. 1), with the following findings: No evi dence of hydrocephalus and otherwise normally developed and healthy child. On the eighth day after birth, without any anesthesia, punctured the cyst, resected the sac and replaced the protruding cerebral tissue. He then made a skin flap closure, postponing the possible bony flap to a later date. Primary union resulted and by the aid of artificial feeding the baby progressed, so that at the end of eight weeks it had gained two pounds in weight. Gradually there was a recurrence of the encephalocele, and the development of a hydrocephalus, which, in spite of repeated puncture and aspiration of from fifteen to twenty cubic centimeters of fluid, finally terminated fatally at the tenth week. Post-mortem examination: The bones of the calvarium were very soft; the dura normal; the arachnoid and pia mater negative; no cerebrospinal fluid in evidence and the lateral ventricles appeared to be empty. In the occipital bone, close to the coronal suture, in the middle line, independent of the posterior fontanelle, was a defect, round and about one and a half centimeters in diameter. The meninges were continuous through this defect into the remaining sac (meningocele), which showed its previous operative interference, it being adherent to the overlying skin. The brain showed no evidence of any gross lesion, and the lateral ventricles contained a small amount of normal cerebrospinal fluid. The tem |